Peroperative administration of tranexamic acid in sleeve gastrectomy to reduce hemorrhage: a double-blind randomized controlled trial

Unraveling Postoperative Bleeding Dynamics in Laparoscopic Roux-en-Y Gastric Bypass: Insights from a Single-Center Tranexamic Acid Study

BACKGROUND

The efficacy of postoperative tranexamic acid (TXA) administration in mitigating bleeding after primary laparoscopic Roux-en-Y gastric bypass (RYGB), a prevalent complication associated with significant morbidities and mortality, and the use of sequential laboratory parameter changes in bleeding screening and TXA impact tracking were investigated.

METHODS

This retrospective analysis included RYGB patients (aged 18-65 years, with a body mass index of 35-50 kg/m2) over 5 years who were categorized into three groups by evolving treatment regimens: Group A (n = 42) received standard pre- and postoperative enoxaparin (30 mg) every 12 h; Group B (n = 160) received enoxaparin and postoperative TXA (250 mg every 6 h); and Group C (n = 73) received TXA alone. Postoperative bleeding-related adverse events, vital signs, and laboratory changes were compared.

RESULTS

Postoperative hemorrhage occurred in 3.6% (10/275) of patients, with no significant intergroup differences. Patients who experienced bleeding had greater decreases in hemoglobin (∆Hb) (2.1 vs. 1.4; p = 0.003), greater ∆Hb > 2 (50% vs. 15%; p = 0.013), and greater use of staples than did those who did not experience bleeding (8 vs. 7; p = 0.001). The ∆Hb values were lower in Groups B (1.4) and C (1.3) than in Group A (1.7, p = 0.011). No significant difference was noted between Groups C and B.

CONCLUSION

This study emphasizes the potential of TXA to mitigate postoperative bleeding after RYGB, with no added benefit from excluding enoxaparin. Monitoring patients with a ∆Hb > 2 mg/dl and increased stapler usage is crucial. Further research is needed to validate routine TXA use across different procedures.

Peroperative administration of tranexamic acid in Roux-en-Y and one-anastomosis gastric bypass to reduce haemorrhage in patients with morbid obesity: protocol for randomised controlled trial (PATRY trial)

INTRODUCTION

By implementation of Enhanced Recovery After Bariatric Surgery protocols and day-care surgery, early discharge poses a challenge if excessive bleeding occurs after bariatric surgery. Tranexamic acid (TXA) has demonstrated efficacy in other surgical fields and in bariatric pilot studies. This trial aims to assess the efficacy of peroperative administration of TXA in reducing haemorrhage in patients undergoing gastric bypass surgery.

METHOD AND ANALYSIS

This is a multicentre, phase III, double-blind randomised controlled trial in six high-volume bariatric centres in the Netherlands. A total of 1524 eligible patients, aged 18 years or older, undergoing primary gastric bypass surgery (either Roux-en-Y gastric bypass or one-anastomosis gastric bypass) will be randomised between TXA and placebo (1:1, variable block, stratified for centre, day-care/overnight stay and type of surgery) after obtaining informed consent (2.5% less haemorrhage, power 80%, 2-sided-α 0.05 and 10% dropout). Exclusion criteria are pregnancy, amedical history of acute bleeding (without cause), venous thrombotic events (VTEs), epilepsy, anticoagulant use and iatrogenic bleeding during surgery (aside from staple line). The primary outcome is postoperative haemorrhage requiring intervention within 30 days postoperatively. Secondary outcome measures are staple line reinforcement, blood loss, duration of surgery, postoperative haemoglobin, vital parameters, minor and major complications, side effects of TXA (nausea, hypotension and VTE), length of hospital stay and directly made costs.

ETHICS AND DISSEMINATION

Written informed consent will be obtained from all participants. The protocol has been approved by the Medical Research Ethics Committees United, Nieuwegein, on 7 February 2023 (registration number: R22.102). Results will be disseminated through peer-reviewed publications and conferences.

TRIAL REGISTRATION NUMBER

NCT05464394.

Feasibility of same-day discharge after laparoscopic sleeve gastrectomy in the Netherlands

BACKGROUND

There is a trend towards laparoscopic sleeve gastrectomy (SG) with same-day discharge (SDD), as an efficient healthcare pathway to alleviate the burden on clinical capacity. This approach seems to be safe, if patients are carefully selected. In our bariatric center, a protocol for Roux-en-Y gastric bypass with SDD has already been successfully implemented. The aim of this study was to evaluate feasibility of applying the same SDD protocol for SG.

METHODS

A single-center prospective feasibility study was conducted at a high-volume bariatric center. Low-risk patients who were scheduled for primary SG were included. Strict criteria were used for approval upon SDD. The primary outcome was the rate of successful SDD without readmission within 48 h. Secondary outcomes included short-term complications, emergency department visits, readmissions, and mortality.

RESULTS

Fifty patients were included in the study, of whom 45 were successfully discharged on the same day of the surgery. Nausea and vomiting were the most common reasons for overnight hospitalization (three patients). One patient was readmitted within the first 48 h due to a mild complication related to bleeding, resulting in a success rate of 88% for SDD without readmission within 48 h. No severe complications or mortality were reported in the cohort.

CONCLUSION

Our SDD protocol for SG has demonstrated feasibility, with a high success rate of SDD and no severe complications. Strict conditions should be met for the safe implementation of a SDD protocol, including careful patient selection and the establishment of a safety net to detect early complications.

The Role of Tranexamic Acid in Sleeve Gastrectomy: A Systematic Review and Meta-Analysis

Tranexamic acid (TXA) is an essential procoagulant drug used in various intra- and postoperative situations. Its efficacy and safety profile in obese cases undergoing laparoscopic sleeve gastrectomy (LSG) is still unresolved. Therefore, this meta-analysis evaluated and investigated the current intra- and postoperative effects and hazards of TXA on patients undergoing LSG. As for methodology, Web of Science, Cochrane Library, Scopus, and PubMed were thoroughly searched for relevant studies. Retrieved results were prepared for screening through Endnote, helping to identify eligible studies. Relevant patient characteristics and outcomes were extracted. The methodological quality of the relevant studies was appraised using the respected appraisal tool. Six studies of different designs were enrolled, comprising 753 cases that underwent LSG and administered TXA. Their mean BMI and age went from 37.3 to 56.25 kg/m2 and 33.5 to 43.25 years, respectively. Tranexamic acid significantly linked to reduction in intraoperative bleeding instances, operative blood loss, and operative duration, compared to placebo ((RR = 0.66, 95% CI [0.44, 0.98], P=0.04, I2 = 81%); (MD = -39.64, 95%CI [-75.49, -3.78], P=0.03, I2=94%); (MD=-5.84, 95%CI [-9.62, -2.05], P=0.003, I2=73%)). Tranexamic acid also significantly showed superiority regarding postoperative bleeding events and duration of hospitalization compared to the control group ((RR= 0.45, 95%CI [0.29, 0.69], P=0.0002, I2 =0%); (MD=-0.24, 95%CI [-0.32, -0.17], P< 0.0000, I2 =0%)). Moreover, follow-up of the enrolled patients for a minimum of three to six months resulted in no reported thromboembolic instances, suggesting a negligible risk for thromboembolism among patients undergoing LSG and receiving TXA. In conclusion, tranexamic acid demonstrates a robust safety and efficacy profile for its use in patients undergoing LSG, with no reported instances of thromboembolism. Variations in TXA administration regimens, bleeding definitions, procedural techniques, and potential confounding medications could not be accounted for, necessitating additional large-scale RCTs to address and bridge knowledge gaps.